Provider Demographics
NPI:1982208674
Name:ISHEE, BRAD
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:ISHEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 REUNION BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8095
Mailing Address - Country:US
Mailing Address - Phone:601-906-5557
Mailing Address - Fax:
Practice Address - Street 1:191 REUNION BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8095
Practice Address - Country:US
Practice Address - Phone:601-906-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist